Pharm #4 Flashcards by zerlina leilanimalulanimekealoha

Q

Seizure disorder

A

Epilepsy

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Q

Abnormal electric discharges from cerebral neurons

A

Seizure disorder

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Q

Seizure disorder Characteristics

A

Loss of consciousness
Involuntary, uncontrolled movements

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Q

Seizure disorder Causes

A

Idiopathic
Secondary
Isolated seizures

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Q

Neurological disorder

A

Epilepsy

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Q

____ of the seizures are unknown reason

A

75% Epilepsy

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Q

____ related to brain injury, trauma, anoxia, infection, cerebral vascular disorders (Stroke)

A

25% Epilepsy

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Q

Chronic condition lasting a lifetime-

A

epilepsy, long term tx

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Q

If seizure nonrelated to epilepsy

A

electrolyte imbalance and hypoglycemia

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Q

International Classification of Seizures

A

Generalized and Partial

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Q

Generalized seizure definition

A

Both hemispheres of the brain

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Q

Types of Generalized Seizures

A

Tonic-Clonic (Grand-Mal)
Absence (petit mal)

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Q

Tonic-Clonic (Grand-Mal)

A

Most common generalized alternating muscle spasms, extremities jerking, tonic phase of the muscles contracting, colonic phase spasming and jerking.

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Q

Absence (petit mal)-

A

seen in children, causes sudden and brief loss of consciousness

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Q

Partial Seizure Definition

A

One hemisphere of the brain, can progress into generalized seizures

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Q

Types of Partial Seizure

A

Simple Partial and Partial complex

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Q

Simple Partial-

A

No loss of consciousness

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Q

Partial complex-

A

Loss of consciousness

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Q

Antiseizure Drugs

A

Anticonvulsants or antiepileptic drugs

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Q

Antiseizure Drugs Basic Action:

A

Stabilize nerve cell membranes
Suppress abnormal electric impulses in cerebral cortex

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Q

Antiseizure Drugs Specific Types of Action:

A

Suppress sodium influx into the cells which inactivates the sodium channel, prevents neurons from firing the electrical impulses
Suppress calcium influx- preventing the electrical current generated by those calcium ions
Enhance action of GABA- amino acid that is inhibiting the neurotransmitters in the brain

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Q

Antiseizure Drugs Dosing

A

Start low of antiseizure medication to get a therapeutic drug serum level
Consistency- need to take these medications at the same time everyday
Hard to control so they have to try multiple meds

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Q

CNS depressants because it depresses CNS function

A

Antiseizure Drugs

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Q

Effective in 75% of patients with seizures

A

Antiseizure Drugs

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Does not cure seizures it manages the symptoms

Antiseizure Drugs

Taken for lifetime

Antiseizure Drugs

If not seizure activity for 3-5 years

Antiseizure Drugs

First group of anti seizure meds developed in 1938. prototype for antiseizure drugs

Hydantoins

Phenytoin (Dilantin)

Hydantoins

Phenytoin (Dilantin) Action

Inhibits sodium influx into the nerves cells, decreasing neuron from firing

Phenytoin (Dilantin) Dosing

Decrease dose with lower metabolism and liver disease. Increased dose for someone (children with high function liver) with a high metabolic rate. Age-related Based on serum drug levels.

Phenytoin (Dilantin) Therapeutic serum level

10 to 20 mcg/mL

Phenytoin (Dilantin) Contraindications

Pregnancy- Teratogenic drug

Phenytoin (Dilantin) Benefit

Slightly sedating and not addictive- benefit

Phenytoin (Dilantin) Highly protein bound=

more free drug= more risk of toxicity

Psychiatric effects- Depression or suicidal ideation

Phenytoin (Dilantin) Side effect

Nystagmus- involuntary eye movement, diplopia- double eye vision

Phenytoin (Dilantin) Side effect

Headache, dizziness, drowsiness(can occur at a therapeutic drug level)

Phenytoin (Dilantin) Side effect

N/V, constipation

Phenytoin (Dilantin) Side effect

Gingival hyperplasia- overgrowth of the gums that causes easily bleeding, normal side effect at a therapeutic level

Phenytoin (Dilantin) Side effect

Alopecia- hair loss hirsutism- excessive body hair

Phenytoin (Dilantin) Side effect

Discolored urine- pink or red, brownish. educate clients, normal side effect

Phenytoin (Dilantin) Side effect

Hyperglycemia- happens in long-term use, inhibits release of insulin. Blood sugar checks

Phenytoin (Dilantin) Side effect

Blood dyscrasias0 thrombocytopenia(low platelet) leukopenia(low WBC counts)

Phenytoin (Dilantin) Side effect

Purple glove syndrome- swelling discoloration and decrease blood flow to the hands can require amputation

Phenytoin (Dilantin) Side effect

Stevens-Johnson syndrome- Rare, effects skin, mucus membranes, genitals and eyes. Flu-like symptoms and painful rash that causes blisters. Educate flulike or rash report immediately. Life threatening

Phenytoin (Dilantin) Side effect

Phenytoin Drug Interactions: Anticoagulants & ASA-

displace the anticoagulant (beats it), adds longer acting time of the anticoagulant

Phenytoin Drug Interactions: Barbiturates, rifampin, & alcohol-

increase metabolism, may need a higher dose

Phenytoin Drug Interactions: Sulfonamides and cimetidine-

can increase action of a hydantoin by inhibiting liver metabolism.

Phenytoin Drug Interactions: Antacids, calcium preparations, sucralfate, and antineoplastic-

Decrease the absorption

Phenytoin Drug Interactions: Antipsychotics and certain herbs-

decrease the seizure threshold, lowers drug therapeutic range, low enough so a seizure can be induces.

Highly protein bound drug it competes with other highly protein bound drugs for the receptor sites

Phenytoin

Phenytoin Assessment

Med history Renal and hepatic lab function values Urinary output Kidney function is appropriate to excrete the drugs Level of knowledge(compliance) Ask about seizure history, is it chronic, is it related to a fever etc.

Phenytoin NSG Interventions

Monitor drug levels of antiseizure drugs to determine therapeutic range. If increased number of seizures ask them about drug regimen and assess serum drug level. Use seizure precautions. Always address nutritional intake (electrolytes balanced, well balanced diet) because the amount of caloric intake.

Phenytoin Education

Compliant and consistent with medication regimen. If female client is taking an oral contraceptive and taking an antiseizure drugs they need to change contraceptive. Do not stop abruptly. Once in steady state in the system they must be weaned off of it. If the client is already diabetic, blood sugar levels will increase so they have to monitor BGL. Avoid alcohol, decrease serum drug levels, effectiveness. Any seizure meds, keep a log of their seizure medications for neurologist to show times and triggers.

Phenobarbital

Barbiturate

Phenobarbital Action

Enhances GABA activity, reduce the excitability of the CNS

Phenobarbital Used to tx

Tonic–clonic, partial, status epilepticus

Longer than 5 minutes seizures or so close together that the pt cannot recover in-between

status epilepticus

Phenobarbital Therapeutic serum range

15 to 40 mcg/mL Wider therapeutic range, longer half life, allows for once daily dosing regimen. More effective for someone because its a longer acting drug (once a day)

Phenobarbital Side effects

Sedation tolerance-gradually withdrawal decreased teratogenic risk- safest drugs for pregnancy and seizures

Phenobarbital Discontinuation

Should be gradual

What type of acting barbiturate is Phenobarbital

Long acting barbiturate

What type of acting are Sedative hypnotics

Short acting

Ethosuximide (Zarontin)

Succinimides

Ethosuximide (Zarontin) Action

Decreases calcium influx which prevents the electrical current generated by the calcium ions

Ethosuximide (Zarontin) Use to tx

Absence seizures (petit mal)- found in children

Ethosuximide (Zarontin) Therapeutic serum range-

40 to 100 mcg/mL wide therapeutic range

GI upset- educate to take with food

Ethosuximide (Zarontin) Side effects/Adverse effects

Dizziness, drowsiness, headache, nightmares

Ethosuximide (Zarontin) Side effects/Adverse effects

Suicidal ideation

Ethosuximide (Zarontin) Side effects/Adverse effects

Gingival hyperplasia- measurable side effect and manageable, does not mean toxic level

Ethosuximide (Zarontin) Side effects/Adverse effects

Ataxia- lack of coordination

Ethosuximide (Zarontin) Side effects/Adverse effects

Blood dyscrasias

Ethosuximide (Zarontin) Side effects/Adverse effects

Renal and liver impairment

Ethosuximide (Zarontin) Side effects/Adverse effects

Systemic lupus erythematous -Once med is stopped= SLE will stop

Ethosuximide (Zarontin) Side effects/Adverse effects

Can have anti seizure effects

Benzodiazepines

Benzodiazepines that have anti seizure effects

Clonazepam (Klonopin) Clorazepate dipotassium (Tranxene) Diazepam (Valium)

Treats absence seizures Tolerance may occur in 6 months of starting therapy, increase dosage after that time frame

Clonazepam (Klonopin)-

Treats partial seizures and anxiety, alcohol withdrawal

Clorazepate dipotassium (Tranxene)

Treats status epilepticus (drug of choice) Must be administered IV for status epilepticus Short-term effect- used with longer acting seizure medications Used for anxiety and induce sedation

Diazepam (Valium)

Carbamazepine (Tegretol)- most commonly used drug in this drug class

Iminostilbenes

Carbamazepine (Tegretol) Tx

Tonic–clonic, partial seizures Also used for psychiatric disorders (BPD), nerve pain (trigeminal neuralgia, diabetic neuropathy), and alcohol withdrawal

Carbamazepine (Tegretol) Therapeutic serum range

4 to 12 mcg/mL (narrow TR) Monitor drug serum level closely

Carbamazepine (Tegretol) Side Effects

Dizziness, drowsiness, headache, blurred vision GI distress Ataxia Weakness Anemia Agranulocytosis- low WBC count Stevens-Johnson syndrome- rare

Grapefruit juice increases bioavailability of this drug, increasing risk for drug toxicity

Carbamazepine (Tegretol)

Valproic Acid (Depakote) Uses

tonic–clonic & absence

Valproic Acid (Depakote) Therapeutic serum range

50 to 100 mcg/mL Wide therapeutic range

Valproic Acid (Depakote) Side effects/Adverse reactions

Dizziness Drowsiness Insomnia Diplopia Weakness GI distress Suicidal ideation Thrombocytopenia Hepatotoxicity- major adverse reaction, monitor liver labs closely

Not safe for children under the age of 2

Valproic Acid (Depakote)

Antiseizure Drugs and Pregnancy: Seizure episodes can increase and

Teratogenesis

Antiseizure Drugs and Pregnancy: ____ are linked to cardiac defects, cleft lip, palate defects

Phenytoin & Carbamazepine

Antiseizure Drugs and Pregnancy: Occur in small percentage of infants, 4-8% chance of congenital defects if they take it during pregnancy

Valproic acid

Antiseizure Drugs and Pregnancy: least amount of effects on fetus

Phenobarbital

Antiseizure Drugs and Pregnancy: Inhibits vitamin k- seizure medications, baby has an increased risk of clotting. Should take a vitamin K supplement a week-10 days before delivery and baby receive vitamin k injection

Vitamin K

Antiseizure Drugs and Pregnancy: Risk for neural tube defects.

Increase Folic acid

Seizures in pregnant women can increase by __ because of increased metabolism rate during pregnancy Hypoxia can occur- mother and fetus at risk (placental blood flow)

25%

More than one drug to have a decrease seizure activity in pregnancy bc of metabolic rate

increases

Antiseizure Drugs and Febrile Seizures: Febrile Seizures-

increase in body temp, most commonly seen of 3 month-5yrs. About 2.5% of children who have febrile seizures develop epilepsy.

Antiseizure Drugs and Febrile Seizures: Seizures associated with

fever

Antiseizure Drugs and Febrile Seizures: Development of epilepsy is

uncommon

Antiseizure Drugs and Febrile Seizures: Prophylactic treatment for high-risk patients- if using preventative meds

Phenobarbital Diazepam

Preventative seizures meds are not indicative Only at a high risk for developing seizures

Antiseizure Drugs and Febrile Seizures

Antiseizure Drugs and Status Epilepticus: Medical

emergency

Antiseizure Drugs and Status Epilepticus: Needs

Tx

Antiseizure Drugs and Status Epilepticus: Diazepam IV (drug of choice, benzo) or Lorazepam IV followed by

Followed by IV Phenytoin or Phenobarbital

Antiseizure Drugs and Status Epilepticus: Continued Seizures worry about (sedation, depression, respiratory) Used for surgical procedures, depression of CNS

Midazolam-versed Propofol

If not treated it can result in death

Status epilepticus

What is the highest priority nursing diagnosis for a patient taking phenytoin (sedative effect, dizziness, ataxia)?

Risk for falls

Before administering a daily dose of phenytoin, it is most important for the nurse to

check phenytoin levels. 10-20 therapeutic range, narrow

When assessing a patient taking hydantoin therapy for seizure disorder, which indicates an adverse reaction to this therapy?

Thrombocytopenia (blood dyscrasias)

A patient is experiencing status epilepticus. The nurse anticipates immediate administration of which drug?

Diazepam

Chronic progressive neurologic disorder

Parkinson’s Disease Pathophysiology

Degeneration of dopaminergic neurons leading to a lack of dopamine

Parkinson’s Disease Pathophysiology

Imbalance of neurotransmitters not enough dopamine compared to acetylcholine

Parkinson’s Disease Pathophysiology

No cure, effects the extrapyramidal system, controls out posture balance and locomotion

Parkinson’s Disease

Results from loss of neurons that are producing dopamine, part of the brain called the substantia nigra

Parkinson’s Disease

Dopamine controls excitatory response from the acetylcholine

Parkinson’s Disease

Too much acetylcholine stimulates too much GABA which causes the symptoms

Parkinson’s Disease

Effects more men than women

Parkinson’s Disease

Can occur with Carbon monoxide and manganese poisoning

Parkinson’s Disease

Pseudoparkinsonism

Result of getting Parkinson like symptoms that are caused by other drugs Frequently occurs as an adverse reaction to various drugs

Pseudoparkinsonism causing meds

Chlorpromazine Haloperidol Lithium Metoclopramide Methyldopa Reserpine

Parkinson’s Disease Characteristics

Involuntary tremors of limbs (extremities) Rigidity of muscles Bradykinesia – slow movements Postural changes- head and chest pushed forward and shuffling gait Lack of facial expression Pill-rolling motion of hands Extrapyramidal system- posture effected, rebalance themselves by compensating

Nonpharmacologic measures for Parkinson’s Disease:

Exercise, Nutrition, and Group support

Exercise-

Improve mobility and flexibility, used to help slow the decline in the quality of life

Nutrition-

fiber and fluids diet to prevent weight loss and constipation. Constantly tremoring, caloric intake and output equal imbalanced

Group support-

family members/caregivers because of chronic progressive disease, coping

Parkinson’s Disease Treatment

Anticholinergics, Dopamine replacements, Dopamine agonists, MAO-B inhibitors, COMT inhibitors,

Anticholinergics-

blocking receptors of acetylcholine bc too much. Allows dopamine balance to be restored

Dopamine replacements-

replacing endogenous dopamine and binding with dopamine receptors

Dopamine agonists-

dopamine replacement, stimulating dopamine receptor

MAO-B inhibitors-

inhibits monoamine oxidase b enzyme, involved in the metabolism of dopamine, decrease dopamine metabolism to increase dopamine receptors. Inhibiting the break down

COMT inhibitors- catechol o methyltransferase

Enzyme that deactivates dopamine, inhibiting that from occurring. Allows more dopamine to be available. Antagonist agonist

Replace dopamine and reduce symptoms

Parkinson’s Disease Treatment

Antiparkinson Drugs

Anticholinergics

Anticholinergics Example

Benztropine & Trihexyphenidyl

Benztropine & Trihexyphenidyl Action

Reduces rigidity and some of the tremors Minimal effect on bradykinesia

Benztropine & Trihexyphenidyl Side effects

Blurred vision Mydriasis Ocular hypertension (Glaucoma contra) Weakness Dry mouth (regulate drooling), Constipation Anhidrosis(decreased sweating) Urinary retention

Activating the nicotinic receptors and muscuenic receptors through out the body

Anticholinergics

Helps reduce the muscle tone and tremors, does not have good effect on the bradykinesia

Anticholinergics

Also used to treat pseudo Parkinson, drug induced Parkinson's

Anticholinergics

Antiparkinson: Anticholinergic Agent Assessment

Full medical history looking for glaucoma and parkinsonism Worried if they already have GI constipation, dysfunction, urinary retention, myasthenia gravis Drug history, Antihistamine can increase the effect of an anticholinergic (trihexyphenidyl) Baseline vital signs See the stage of Parkinson disease progression, current s/sx. Know ability for drug regimen. Baseline urinary output for urinary retention

Antiparkinson: Anticholinergic Agent NSG Interventions

vital signs urinary retention bowel movements watch for increase pulse rate hypervolemia constipation, monitor effects on drugs and how effective they are on symptoms.

Antiparkinson: Anticholinergic Agent Education

Safety measures- safety bar in shower, elevated toilet seat, shower chair, removing throw rugs. Adding extra lighting, eliminating danger.

Dopaminergics

Antiparkinson Drugs

Dopaminergics Example

Carbidopa-levodopa

Carbidopa

Prolongs the effect of levodopa

Carbidopa-levodopa action

Converts to dopamine and increases mobility

Carbidopa-levodopa Side effects

Fatigue, insomnia, dry mouth, blurred vision Orthostatic hypotension- seen beginning the TX, decreases overtime, palpitations, dysrhythmias, Agranulocytosis Constipation, N/V, urinary retention, urine discoloration Dyskinesia- involuntary movements, psychosis, severe depression- report immediately

Dopamine itself cannot cross BBB but

levodopa can by converting into dopamine

___ inhibits the enzyme decarboxylase that’s breaking down levodopa in the body

Carbidopa

levodopa turns into dopamine = increasing levels of

dopamine

When levodopa is used alone, only __ reaches the brain because __ converts to dopamine while in the peripheral nervous system

1% 99%

By combining carbidopa with levodopa, carbidopa can inhibit the enzyme __ in the periphery, thereby allowing more levodopa to reach the brain.

decarboxylase

Levodopa taken alone-

10mg of 500mg reaches the brain, 5%

When carbidopa given with levodopa a smaller dose-

10mg of 100mg gets to the brain = 10% effectiveness, decreases side effects

Dopaminergics (carbidopa-Levodopa) Asessment

vital sign baseline, drug history, medical history, s/sx

Dopaminergics (carbidopa-Levodopa) Nursing Interventions-

orthostatic hypotension increase water and salt intake take carbidopa and levodopa with low protein foods. High protein food effects/blocks how the drug goes to the CNS

Dopaminergics (carbidopa-Levodopa) Education

Family support and educating support system drug regimen is taken properly Short half life- 1-2 hrs. Need to take frequently through out the day, cannot abruptly stop med can cause rebound symptoms. Can cause urine discoloration-will darken with exposure to the air- harmless. Perspiration(Sweat) not clear, educate. Can be taken with food (low protein), can cause GI upset. If given with food, absorption can be delated. Therapeutic response takes several months, educate to not stop taking med.

Bromocriptine(dopaminergic)

Dopamine Agonists

Bromocriptine(dopaminergic) Action

Acts directly on dopamine receptors in CNS, cardiovascular system, & GI tract Used when pts do not tolerate carbidopa-levodopa

Dopamine agonist direct acting Can be taken alone or with carbidopa-levodopa, when given together the dosages of each can be decreased. Can reduce side effects and drug tolerance

Bromocriptine(dopaminergic)

Selegiline

Monoamine Oxidase B Inhibitors

Selegiline Action

Inhibit MAO-B enzyme that interferes with dopamine

Selegiline Interaction

Food high in tyramine can cause hypertensive crisis CNS toxicity with tricyclic antidepressants or SSRIs

Breaks down dopamine enzyme, Inhibiting from occurring

Selegiline

The action of dopamine in levodopa is prolonged

Selegiline

Used as early tx before carbadop-levodopa

Selegiline

Large doses of MAO B inhibitor can inhibit MAO A enzyme

Selegiline

When drug is not metabolized well it can cause hypertensive crisis- too much tyramine in the body= aged cheese, beer, red wine, bananas. Educate to prevent tyramine

Selegiline

Tolcapone & Entacapone

Catechol-O-Methyltransferase COMT Inhibitors

Tolcapone & Entacapone Action

Inhibit COMT enzyme that inactivates dopamine. Increase the amount of dopamine Often combined with carbidopa-levodopa. Can decrease both dosages

Hepatoxic (liver enzymes)

Tolcapone

less risk for liver toxicity but cause brown/orange urine. No effect on liver fxn

Entacapone

Form of Incurable dementia illness

Alzheimer’s Disease

Chronic, progressive neurodegenerative disorder

Alzheimer’s Disease

Onset usually between ages 45 and 65

Alzheimer’s Disease

Alzheimer’s Disease Pathophysiology

Cholinergic neuron degeneration and acetylcholine deficiency Neuritic plaques/neurofibrillary tangles

Alzheimer’s Disease Etiology- unknown

Genetics, can be caused by damage of the brain cells, virus, infection, nutritional deficiencies folic acid decrease Others. Cholinergic neurons that produce acetylcholine degernate which leads to decreased acetychoe. It is crucial in forming memoires

Neurodegenerative disorder

Alzheimer’s Disease

Increased marked cognitive dysfunction

Alzheimer’s Disease

Can give meds to try and slow progression of symptoms

Alzheimer’s Disease

Can cause sedentary lifestyle.

Alzheimer’s Disease

Occur more in women than in men, risk more occurrence bc women live longer

Alzheimer’s Disease

Alzheimer’s Disease Pathophysiology Histologic changes

Neuron affected by Alzheimer’s disease showing characteristic neuritic plaques and cellular neurofibrillary tangles.

Alzheimer’s Disease Mild (early stage)

still living independently, trouble planning and organizing, memory loss

Alzheimer’s Disease Moderate (middle stage)

increased memory loss, personality changes, not able to perform routine tasks, loss of bowel and bladder control

Alzheimer’s Disease Severe (late stage)-

severe cognitive impairment, not recognize people, a lot of adl assistance, not walking or talking often, ability to lose swallow effect worried about aspiration

Rivastigmine & Donepezil

Acetylcholinesterase/Cholinesterase Inhibitors

Rivastigmine & Donepezil Action

Inhibit the action of acetylcholinesterase Cause increased levels of acetylcholine in the CNS Increase cognitive function and delay loss of brain function

Rivastigmine & Donepezil Side effects

Related to an increase in acetylcholine in the peripheral nervous system as well Parasympathetic response- bronchoconstriction, bradycardia, hypotension

Rivastigmine & Donepezi Treats

Mild to moderate Alzheimer's disease

Rivastigmine (Exelon) Side effects/Adverse effects (results from parasympathetic nervous system activation)

Anorexia Abdominal pain N/V Diarrhea or constipation Weight loss Dizziness HA Depression Confusion Peripheral edema Dry mouth Dehydration Nystagmus Seizures Bradycardia Orthostatic hypotension Cataracts MI, HF, dysrhythmias Hepatoxicity Suicidal ideation Steven-Johnson’s syndrome

Rivastigmine (Exelon) Drug Interactions

Theophylline, general anesthetics- increase effect, if going into surgery they may discontinue before TCAs- decrease effect Cimetidine- increase effect NSAIDs- for other pain/inflammation, increases GI effects Tobacco

Transdermal patch or tablet form, 2x a day, mild to moderate Alzheimer's

Rivastigmine (Exelon)

Rivastigmine Assessment

Stage of disease, physically and mentally able to do, support system look like. Maintain consistency and care- same staff members.

Rivastigmine NSG interventions

Assisting with ambulation and activity. Goal to help independence as possible. Monitor side effects. Noting improvement or decline in function

Rivastigmine Education

home safety, side effects, reason for drug regimen, info about support groups

Memantine (Namenda)

NMDA receptor antagonist

Memantine (Namenda) Action

Blocks effects of neurotransmitter glutamate at NMDA receptors

Memantine (Namenda) Side effects/adverse effects

Fewer than acetylcholinesterase inhibitors Most common: Dizziness, HA, drowsiness, confusion, constipation or diarrhea Stevens-Johnson syndrome Depression, Hallucinations Hyper or hypotension, urinary incontinence

Learning capability and memory- NMDA

Memantine (Namenda)

Tx moderate to severe Alzheimer's

Memantine (Namenda)

A patient has been diagnosed with Alzheimer disease. The patient’s daughter asks the nurse what the cause of Alzheimer disease is. The best response by the nurse is “The cause of Alzheimer disease is

unknown.”

Which comment to the nurse indicates more teaching is needed for a patient taking carbidopa/levodopa?

“I know I need to take this drug once a day.”

Which side effect/adverse effect of carbidopa/levodopa does the nurse realize is most important to monitor?

Agranulocytosis- decrease in WBCs

Before administering carbidopa–levodopa for the treatment of Parkinson’s disease, it is most important for the nurse to assess the patient for a history of

glaucoma

A patient with Parkinson’s disease is being treated with carbidopa–levodopa. The daughter asks the nurse why he needs both agents. The nurse responds,

“The carbidopa helps the levodopa reach the brain.”

A nurse at an adult day care center notes that many patients are on rivastigmine. The nurse knows that the function of this medication is to

slow the progression of symptoms of Alzheimer disease.

Autoimmune disorder

Myasthenia Gravis Pathophysiology

Antibodies attach to acetylcholine receptor sites, obstruct binding of acetylcholine, and destroy receptor sites

Myasthenia Gravis Pathophysiology

Lack of acetylcholine impairs transmission of messages at neuromuscular junctions

Myasthenia Gravis Pathophysiology

Non-curable

Myasthenia Gravis

Myasthenia Gravis Result

Respiratory, facial, and extremity weakness Muscles that are not getting their receptor sites fulfilled

___ is the neurotransmitter for the parasympathetic nervous system

Acetylcholine

Myasthenia Gravis occurs more in women of child bearing age years =

20-40yrs

Myasthenia Gravis peak male age

50-70

Tend to run in families

Myasthenia Gravis

Lymph organ

Myasthenia Gravis: Thymus Gland

Produces T cells

Myasthenia Gravis: Thymus Gland

Enlarged in 60% of MG patients- produce antibodies that add acetylcholine to receptor sites. Over production of antibodies occur.

Myasthenia Gravis: Thymus Gland

Remove the thymus gland, reduce number of antibodies

Myasthenia Gravis: Thymectomy

Skeletal muscle weakness

Myasthenia Gravis Characteristics

Fatigue, ptosis, diplopia, dysphagia, dysarthria

Myasthenia Gravis Characteristics

Respiratory muscle weakness, paralysis, and arrest

Myasthenia Gravis Characteristics

Fluctuating muscle weakness especially when someone is using that muscle a lot

Myasthenia Gravis Characteristics

Respiratory arrest due to

paralysis of muscles in the lungs, Myasthenia Gravis

Facial muscles-

Ptosis, difficulty chewing, drooping eyelids, and dysphagia, Myasthenia Gravis

Extremities are the most effected

Myasthenia Gravis

Causes Severe generalized muscle weakness- involve respiratory muscles = death

Myasthenic crisis

Involves diaphragm and intercostal muscles

Myasthenic crisis

Myasthenic crisis triggers

Inadequate dosing of AChE inhibitors Emotional stress, menstrual cycle, pregnancy Infection, surgery, trauma Hypokalemia, alcohol intake Temperature extremes Medication interactions

Treat with neostigmine- a fast acting ACHe inhibitor, prevents breakdown of acetylcholine

Myasthenic crisis

Myasthenic crisis can occur 3-4 hours after taking certain meds=

Aminoglycoside antibiotics, Phenytoin, CCBs, Psychotropics

Usually occurs within 30 to 60 minutes after taking excess anticholinergic medications

Cholinergic crisis

Triggered by overdosing

Cholinergic crisis

Cholinergic crisis symptoms

Severe muscle weakness Possible respiratory paralysis and arrest Miosis (pupil constriction) Pallor, sweating, vertigo Excess salivation, GI distress, vomiting Bradycardia, fasciculations (muscle twitching)

Occurs when too much of an Acetylcholinesterase inhibitor at the receptor sites Nerves are over stimulated when having too much Acetylcholine

Cholinergic crisis

Can cause respiratory arrest

Cholinergic crisis

Antidote: Atropine

Cholinergic crisis

Acetylcholinesterase inhibitors

Edrophonium (Tensilon), Neostigmine, Pyridostigmine

Acetylcholinesterase inhibitor action

Increases muscle strength in patients with myasthenia gravis

Medication differentiating between myasthenic (if it works) and cholinergic crises (if it worsens)

Edrophonium (Tensilon)

Ultra-short-acting- (worsened symptoms resolve quickly), need emergency precautions

Edrophonium (Tensilon)

Short-acting

Neostigmine

Intermediate-acting

Pyridostigmine

Decreasing break down the the acetylcholine at the sites

Acetylcholinesterase Inhibitors

Acetylcholinesterase Inhibitors Side effects

Miosis Blurred vision Bradycardia Hypotension GI distress- Nausea, vomiting, diarrhea, abdominal cramps

PNS stimulation Increase acetylcholine Activates both muscarinic and nicotinic receptor sites

Acetylcholinesterase Inhibitors

Patients Unresponsive to Acetylcholinesterase Inhibitors

Prednisone, Plasma exchange, Intravenous immune globulin, Immunosuppressive drugs

Prednisone-

If the AChe are not effective Drug of choice

Intravenous immune globulin-

IGG

Immunosuppressive drugs

Azathioprine- Intense drug, need to be monitored for hepatotoxicity and leukopenia

Pyridostigmine Assessment-

Drug history Labs S/Sx if being effective or over effective Ability to swallow,

Pyridostigmine Nursing Interventions-

Monitoring and watching for drug effectiveness, S/Sx or myasthenic crisis or cholinergic crisis Make sure family is involved (addressing psychosocial needs)

Pyridostigmine Education-

Follow drug regimen Notifying about other meds to physician Side effects Take meds before meals for best absorption. If taking med at least 30 mins before meals it can increase muscle capability for chewing. Encourage to wear Medical identification bracelet for emergencies (myasthenia and cholinergic crisis)

Autoimmune disorder Attacks myelin sheath of nerve fibers in brain and spinal cord Causes lesions (plaques)

Multiple Sclerosis Pathophysiology

Multiple Sclerosis Motor Characteristics

Motor symptoms- Weakness or paralysis of extremities, fatigue, muscle spasticity, paresthesia

Remissions and exacerbations

Multiple Sclerosis

Multiple Sclerosis Sensory symptoms

Numbness and tingling, double vision (first symptom that they experience), vertigo, tinnitus

Multiple Sclerosis Cerebellar symptoms-

nystagmus, ataxia, dysarthria, and dysphagia

May have neuropathic pain in lower back or abdominal area

Multiple Sclerosis

Slows down nerve impulse transmission

Multiple Sclerosis

No cure Can give meds to slow disease process and improve symptoms

Multiple Sclerosis

Multiple Sclerosis diagnosis is

difficult

Multiple Sclerosis diagnosis

Medical history Neurologic exam MRI Cerebrospinal fluid analysis Evoked potential test

MRI-

lesions in the brain or spinal column

Cerebrospinal fluid analysis-

may have elevated IgG antibodies

Evoked potential test-

measuring electric activity in the brain as the response of stimulation of a nerve pathway

Oligoclonal bands-

proteins that are the product of the myelin sheath breakdown

Multiple Sclerosis Tx:

Immunomodulators and immunosuppressants

Immunomodulators

disease modifying drugs

immunosuppressants

slowing disease process and prevention of relapse of an exacerbation

First-line treatment Slows disease progression and prevents relapses

Immunomodulators and immunosuppressants

Immunomodulators and immunosuppressants example

Beta interferon

Beneficial in reducing edema or acute inflammation that is occurring at the direct area of myelin sheath breakdown.

Multiple Sclerosis tx: Corticosteroids

Used for acute exacerbations not for long term (sick symptoms can worsen), increases BGL on long term meds

Multiple Sclerosis tx: Corticosteroids

Reduces edema and acute inflammation

Multiple Sclerosis tx: Corticosteroids

Corticosteroid example

Methylprednisolone(solumedrol)

Skeletal muscle relaxants

Centrally acting muscle relaxants Direct acting muscle relaxant

Centrally acting muscle relaxants

Relieves muscle spasm and spasticity Have sedative effect

Direct acting muscle relaxants

Decreases muscle spasm pain and increases range of motion Suppresses hyperactive reflex

Skeletal Muscle Relaxants side effects

Drowsiness, dizziness, headache, nausea, vomiting

Used to alleviate muscle spasms and injury that causes it

Skeletal Muscle Relaxants

Sedative effect, do not give any other cns depressants

Skeletal Muscle Relaxants

All muscle relaxants Can cause drug dependence except cyclobenzaprine

Skeletal Muscle Relaxants

Do not put someone on long-term

Skeletal Muscle Relaxants

Can have anticholinergic side effect

Skeletal Muscle Relaxants

Cyclobenzaprine

Skeletal Muscle Relaxants

Cyclobenzaprine action

Relax skeletal muscles

Cyclobenzaprine uses

Relieves muscle spasm

Cyclobenzaprine side effects

Anticholinergic effects- Blurred vision, dry mouth, urine retention, constipation, tachycardia Drowsiness, dizziness Headache, nervousness, confusion GI distress, unpleasant taste Dysrhythmias

Prototype drug of skeletal relaxants

Cyclobenzaprine

Only skeletal relaxant that does not cause dependence

Cyclobenzaprine

Benefits SUD

Cyclobenzaprine

Weaning off drug because can cause muscle spasm rebound

Cyclobenzaprine

Baclofen Carisoprodol (Soma) Chlorzoxazone (Parafon Forte) Methocarbamol

Skeletal Muscle Relaxants

PO, Intrathecally (spinal column)-pump is surgically implanted, catheter into the spinal column. Can be continues or scheduled, gives low continual dose (steady state)

Baclofen

Cyclobenzaprine- Assessment

Drug history and medical history

Cyclobenzaprine- Nsg interventions

Hepatic functions (can become toxic) Observing S/E for CNS depression (still need to function)

Cyclobenzaprine- Education

Cannot be abruptly stopped, should not drive, Not taken more than 3 weeks or less Avoid alcohol. Take with food to decrease GI upset and report other side effects, avoid other CNS depression meds

A patient with myasthenia gravis comes to the emergency department in respiratory distress. He has been diagnosed with myasthenic crisis. The nurse anticipates administration of which drug?

Neostigmine

The patient is admitted to the emergency department with cholinergic crisis. The nurse anticipates administration of

atropine.

A patient with myasthenia gravis comes to the emergency department in respiratory distress. To determine if the patient is in myasthenic crisis or cholinergic crisis, the nurse anticipates administration of which drug?

Edrophonium

A patient with myasthenia gravis is prescribed neostigmine. The nurse identifies that the medication is effective when the patient experiences

increased muscle strength.

A patient with multiple sclerosis is being treated with large doses of corticosteroids. Which nursing diagnosis would be the priority at this time?

Risk for infection

A child with cerebral palsy is ordered to receive baclofen. The nurse is aware that this medication is prescribed to

reduce muscle spasticity.

Depression Etiology

Genetic predisposition Social and environmental factors

Depression Pathophysiology theories

Decreased levels of monoamine neurotransmitters- predisposed to depression when decreased neurotransmitters

Monoamine neurotransmitters

Norepinephrine, serotonin, dopamine

Depression S/Sx

Depressed mood, despair, weight loss or gain Loss of interest in most activities Fatigue, insomnia, hypersomnia Decreased ability to think or concentrate Suicidal thoughts

Whoever is discussing this w them needs to openly address this issue. Ask if they have thought about hurting themselves or others? Do they have plan?

Suicidal thoughts

Most common mental illness, 1/3 of people experience depression ½ of people seek treatment, 2/3 of the tx have remission

Depression

Depression contributing factors:

Hx of abuse Genetic component Experience of illness Traumatic life event Personal problems and Substance abuse (self medicating prescription or elicit)

Types of depression

Reactive depression, Major depression, Bipolar disorder

Reactive depression-

Occur after a precipitating event- death of a loved one, divorce. Can last months.

Major depression Primary-

unrelated to any health problems.

Major depression Secondary-

Related to physical (postpartum depression) or psychiatric disorder or drug misuse

Bipolar disorder-

Mood is fluctuating between manic state (euphoria) and really low depression state

Complementary and Alternative Therapy for Depression

Ginkgo biloba and St. John’s wort, Psychotherapy Somatic therapies, Exercise, Light therapy

Ginkgo biloba and St. John’s wort- decreased reuptake of monoamine neurotransmitter

Discontinue use of herbal products 1 to 2 weeks before surgery. Check with the health care provider before taking herbal treatments.

Somatic therapies

ECT Transcranial magnetic stimulation

ECT

short acting neuromuscular blocker, short acting IV is given

Transcranial magnetic stimulation

magnetic pulses that are directed to the areas of the brain that control mood

Exercise-

releases endorphins

Light therapy-

experiencing seasonal effective disorder

Not be combines with prescription antidepressants- ginkgo. Causes:

Extreme dizziness, headache, sweating= Serotonin syndrome

Antidepressant Groups

Tricyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants Monoamine oxidase inhibitors (MAOIs)

TCAs and MAOIs=

more side effects, not used as often, developed in 1950s. older med.

SSRIs and SNRIs=

1980s, less side effects, more used

Tricyclic Antidepressants Examples:

Amitriptyline Imipramine Trimipramine Doxepin Nortriptyline Protriptyline

Blocks uptake of neurotransmitters norepinephrine and serotonin in brain

Tricyclic Antidepressants Action

Elevates mood, increases interest in ADLs, decreases insomnia

Tricyclic Antidepressants Action

Blocks histamine receptors which leads to sedation

Tricyclic Antidepressants Action

Blocks cholinergic receptors which leads to anticholinergic effects

Tricyclic Antidepressants Action

As effective as SSRIs but have a lot of side effects

Tricyclic Antidepressants

Tricyclic Antidepressants Use

Major depression

It takes 2-4 weeks to become effective, if ineffective in that time frame they need to be tapered off of the med

Tricyclic Antidepressants

Tricyclic Antidepressants Side effects/adverse reactions

Drowsiness, dizziness, blurred vision Dry mouth and eyes, GI distress Urinary retention, sexual dysfunction Weight gain, seizures Suicidal ideation Orthostatic hypotension (Common, CNS depression), dysrhythmias Blood dyscrasias, cardiotoxicity EPS, NMS

Sedation is the major side effect

Tricyclic Antidepressants

Also have anticholingeric effects- tachycardia, urine retention, blurred vision

Tricyclic Antidepressants

Can cause leukopenia, thrombocytopenia, agranulocytosis

Tricyclic Antidepressants

Amatriptaline- Extrapyramidal symptoms

Tricyclic Antidepressants

Clomipramine- cause neuroleptic malignant system, fever, rigidify to muscles, autonomic hyperactivity(SNS stimulation)

Tricyclic Antidepressants

__ can lower seizure threshold- if have epilepsy they need to increase seizure medications

Tricyclic Antidepressants

High doses of __ cause cardiotoxicity and dysrhythmias, can be lethal

Tricyclic Antidepressants

Tricyclic Antidepressants Interactions

Alcohol and other CNS depressants potentiate CNS depression MAOIs may lead to toxic psychosis, cardiotoxicity Antithyroid drugs may increase dysrhythmias

Must wait 2 weeks after stopping MAOI to give ___

Tricyclic Antidepressants

Increased risk for dysrhythmia when taking

methimazole, Tricyclic Antidepressants

Selective Serotonin Reuptake Inhibitors Example

Fluoxetine(Prozac), sertraline, paroxetine, citalopram

Fluoxetine(Prozac)-

Positive results in 50-60% who don’t respond well to a TCA (prototype)

Selective Serotonin Reuptake Inhibitors Action

Block uptake of neurotransmitter serotonin which allows more serotonin to effect the receptor sites=more availability of serotonin

Selective Serotonin Reuptake Inhibitors Uses

Major depression (primary use) Anxiety disorders Prevention of migraine headaches Decrease premenstrual tension syndrome Eating disorders Substance use disorder

Can have Weekly delayed dose, must see daily dosing first

Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors Interactions

Increased sedation with alcohol and other CNS depressants Grapefruit juice with SSRIs can lead to toxicity

Selective Serotonin Reuptake Inhibitors Side effects/adverse reactions

Headache, insomnia Blurred vision Dry mouth, GI distress Erectile dysfunction Suicidal ideation Side effects often decrease over 1 to 4 weeks

More popular than TCA bc they cause less side effects

Selective Serotonin Reuptake Inhibitors (SSRI)

Not much a risk of cardiotoxicity

Selective Serotonin Reuptake Inhibitors (SSRI)

Dosage should be decreased in older clients bc of CNS depression and lower metabolism

Selective Serotonin Reuptake Inhibitors (SSRI)

Can cause increase appetite so weight gain is common

Selective Serotonin Reuptake Inhibitors (SSRI)

S/E decrease libido, nervousness, insomnia, can decreased overtime

Selective Serotonin Reuptake Inhibitors (SSRI)

Monitor for suicidal ideation especially when first beginning tx

Selective Serotonin Reuptake Inhibitors (SSRI)

Should be tapered off, not stopped abruptly

Selective Serotonin Reuptake Inhibitors (SSRI)

Serotonin Norepinephrine Reuptake Inhibitors examples

Venlafaxine, duloxetine, desvenlafaxine

Serotonin Norepinephrine Reuptake Inhibitors Action

Inhibit the reuptake of serotonin and norepinephrine

Serotonin Norepinephrine Reuptake Inhibitors Use

Major depression Generalized anxiety disorder Social anxiety disorder

Serotonin Norepinephrine Reuptake Inhibitors Interactions

St. John’s wort- high risk for serotonin syndrome and neuroleptic malignant syndrome

Serotonin Norepinephrine Reuptake Inhibitors Side effects

Drowsiness, dizziness Insomnia, euphoria Headache, amnesia Blurred vision Erectile/ejaculation dysfunction Elevated liver enzymes

Serotonin Norepinephrine Reuptake Inhibitors Adverse effects

Tachycardia, hypertension Orthostatic hypotension Seizures, suicidal ideation, insomnia

Don’t give to someone with liver disease or alcohol abuse issues

Serotonin Norepinephrine Reuptake Inhibitors

More of a stimulant effect bc of norepinephrine

Serotonin Norepinephrine Reuptake Inhibitors

Atypical Antidepressants examples

Amoxapine, maprotiline, trazadone(common, hypnotic)

Atypical Antidepressants action

Affects neurotransmitters: serotonin, norepinephrine, and dopamine. (effects one or two)

Atypical Antidepressants uses

Major depression, reactive depression, anxiety

Atypical Antidepressants interactions

MAOIs

Atypical Antidepressants Side effects/adverse effects

Dry mouth, blurred vision, orthostatic hypotension Constipation, erectile/ejaculatory dysfunction

Called second generation antidepressants

Atypical Antidepressants

Must be stopped 2 weeks before starting an MAOI

Atypical Antidepressants

Monoamine Oxidase Inhibitors Examples

Tranylcypromine sulfate, isocarboxazide, selegiline, & phenylzine sulfate

Monoamine Oxidase Inhibitors action

Monoamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin

Monoamine Oxidase Inhibitors use

Depression not controlled by TCAs and second-generation antidepressants (Atypical Antidepressants)

Enzyme that inactivates neurotransmitters-

Monoamine Oxidase

High risk of severe adverse effects

Monoamine Oxidase Inhibitors

Should not be taken at the same time of another antidepressant Use is limited

Monoamine Oxidase Inhibitors

Monoamine Oxidase Inhibitors drug interactions

CNS stimulants such as vasoconstrictors and some cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI

Monoamine Oxidase Inhibitors food interactions

Foods containing tyramine

MAOI can be fatal due to

interactions

Phenylephrine- Tylenol (OTC sudafed), Pseudoephedrine with an MAOI can cause

hypertensive crisis

Foods high in tyramine-

Cheese, Yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver, pickled foods, cured meats (salami, pepperoni), soy sauce, yeast, beer, red wine

Monoamine Oxidase Inhibitors Side effects/adverse effects

Agitation, restlessness, insomnia Anticholinergic effects Orthostatic hypotension Hypertensive crisis from tyramine interaction Suicidal ideation

Cause CNS stimulation

Agitation, restlessness, insomnia

Antidepressant Agents Assessment

Drug history, Hepatic and renal function study Health history S/Sx having of depression to treat correctly, Serotonin syndrome and Neuroleptic malignant syndrome. Already on the meds and effectiveness

Antidepressant Agents Nursing Interventions

Giving someone entire list of foods when taking MAOIs. If not compliant need to find different drug

Antidepressant Agents Education-

Drug effectiveness is not going to be immediate. Can take 1-3 weeks to become effective. Cannot stop abruptly. Side effects will decrease overtime. Take meds in the morning, that it will be causing stimulation. Take drugs that cause sedation take in evenings. Don’t consume alcohol or there CNS depressants. If drug has Anticholinergic side effects, not giving this to someone with glaucoma. No driving until they know how they are effected by the meds.

Mood Stabilizer: Lithium

Mood Stabilizer

Lithium therapeutic serum range

0.8 to 1.2 mEq/L (narrow)

Serum lithium levels greater than __ may lead to toxicity

1.5 mEq/L

Lithium Action

Alteration of ion transport in muscle and nerve cells (in sodium) Increased receptor sensitivity to serotonin

Lithium use

Bipolar disorder, manic episodes

Help decrease wide ranges of mood swings that they experience

Lithium

First drug to tx bipolar disorder and still commonly used

Lithium

Need lithium drug serum levels frequently

Lithium

Lithium Side effects/adverse reaction

Drowsiness, dizziness Blurred vision, headache Restlessness, tremors Memory impairment Dry mouth, thirst, metallic taste, GI distress, weight gain/loss Hypotension, dysrhythmias Edema of hands and ankles Increased urination, dehydration

Lithium Early s/sx of toxicity=

diarrhea, drossiness, N/V, slurred speech, and trembling

Lithium Late s/sx of toxicity

burred vision, confusion, large output of dilute urine, and convulsions

Lithium Interactions Increased lithium level with

Thiazides diuretics', methyldopa, haloperidol, NSAIDs, antidepressants, phenothiazines

Lithium Interactions Decreased lithium level with

Caffeine, loop diuretics, theophylline

Lithium Assessment

Evaluating neurological status, gait, LOC, reflexes, and tremors. History- drug/health. Watching renal and hepatic lab functions

Lithium Nursing Interventions-

Early s/sx of toxicity. Monitoring intake and output. Intervening clients who are in manic phase of their bipolar disorder to conserve energy. Checking cardiac function. Electrolytes (sodium important).

Lithium Education-

cautious about driving bc of lithium level. Increase fluid intake in hot weather. Always have adequate intake of 2/3 liters. Avoid caffeine. Can take w meals to decrease GI upset. Teratogenic. Need to be aware of appropriate birth control options to prevent pregnancy

A patient with reactive depression is ordered to receive fluoxetine (SSRI). Which information will the nurse include when teaching this patient?

The medication may cause headaches and insomnia. (take in evening)

Before administering a monoamine oxidase inhibitor, it is most important for the nurse to assess the patient’s

dietary intake.

Which laboratory test is most important for the nurse to monitor when a patient is receiving lithium?

Serum electrolytes (sodium)

When providing dietary teaching for a patient taking monoamine oxidase inhibitors, the nurse should teach the patient to avoid which food?

Yogurt

Which advice will the nurse include when teaching the patient about lithium therapy?

It may take 1 to 2 weeks before you have any benefits from taking the medication. (common for all antidepressants)

Which statement about amitriptyline (TCAs) does the nurse identify as being true?

The drug should be discontinued slowly.